Women who are advised against contralateral prophylactic mastectomy after discussion are not more likely to be dissatisfied or seek a second opinion than those whose surgeon supports the procedure

medwireNews: Breast cancer patient satisfaction with their surgical consultation is not adversely affected by a recommendation against contralateral prophylactic mastectomy (CPM), a survey of US women suggests.

“Guidelines assert that [CPM] should be discouraged in patients without an elevated risk for a secondary primary breast cancer”, explain Steven Katz, from the University of Michigan in Ann Arbor, USA, and co-authors in JAMA Surgery.

However, the rate of CPM has increased in recent years, with the greatest use found among women with an average risk of a second tumour, the researchers note, despite a reduction in the risk of contralateral events with use of adjuvant systemic agents in patients with early breast cancer.

In all, 3880 women treated for stage 0–II breast cancer between 2013 and 2014 in Georgia and California were included in the study, with 40.5% receiving breast-conserving treatment, 22.0% unilateral mastectomy (41.4% with breast reconstruction) and 38.2% CPM (76.7% with breast reconstruction).

Analysis of responses 2 months after surgery from 1140 patients with unilateral breast cancer who had considered CPM revealed that most patients (63.1%) reported discussing CPM as an option with their surgeon. But 30.1% of respondents said they did not have a “substantive discussion” about the procedure and there was missing data for 6.8%.

Whereas 26.7% of patients were recommended against the procedure by their first surgeon, 67.3% were not, with missing data on this result for 6.0%.

Overall, dissatisfaction with their surgical consultation was “uncommon” and reported by just 7.6% of patients, the researchers say.

But, while the rate of dissatisfaction was “very low” among the patients who were recommended against CPM after discussion, it was “substantively higher” among those whose surgeon recommended against CPM without discussion, at 3.9% versus 14.5%.

The authors describe these findings as “largely reassuring” but note that only a “modest” proportion of patients were recommended against CPM by their first surgeon.

“The consequences of a greater number of surgeons advising against CPM are unknown, especially in women who strongly desire the procedure”, they caution.

Nevertheless, women were not significantly more likely to seek a second surgical opinion if their surgeon recommended against CPM than if their surgeon did not (17.1 vs 15.0%). Nor were patients more likely to switch to a second surgeon for their procedure if they were recommended against CPM by their original surgeon (7.9% in both groups).

Indeed, just 20.6% of patients sought a second surgical opinion and 9.8% of chose to undergo surgery with their second surgeon, the authors say.

“For patients who remain uncertain about the benefits of CPM, a second opinion may be an appropriate source of additional information”, the researchers believe.

They conclude: “Research is needed to develop and evaluate both decision tools for patients and training opportunities for surgeons that can facilitate these very important clinical encounters concerning challenging treatment decision issues.”